Indiana Recovery Audit Contractor (RAC) Complex Reviews Webinar February 15, 2013
Webinar Goals Provide information HMS - selected vendor as the Indiana Medicaid RAC Indiana s Medicaid RAC Program Details on HMS Complex Reviews Methodology Approach & Overview Review Process Answer Common Questions 2
HMS Presenters Jeanine Motsay HMS Program Director, Indiana Joleen Bond-Livingston, VP Recovery Audit Glenda Lloyd, Manager, Recovery Audit Coding 3
HMS OVERVIEW JOLEEN BOND-LIVINGSTON VICE PRESIDENT, RECOVERY AUDIT
About HMS We provide cost containment services for healthcare payers We help ensure that claims are paid correctly (program integrity) and by the responsible party (coordination of benefits) As a result, our clients spend more of their healthcare dollars on the people entitled to them 5
Background Recovery Audit Contractor Medicare Modernization Act of 2003 created a demonstration project to identify Medicare overpayments The program was operational from 2005 through 2007 Following success of the demonstration project, the program was made permanent in 2008 Section 6411(a) of the Affordable Care Act expanded RAC to Medicaid and required each State to begin implementation by January 1, 2012 Identification of overpayments and underpayments States & RAC vendor must coordinate recovery audit efforts RAC vendors reimbursed through contingency model 6
HMS- Medicaid RAC Standards Reduce provider abrasion, provide education, customer service and limit administrative costs. Possess in depth knowledge of Indiana Medicaid policies, regulations and MMIS process. Maintain an understanding of the state s operating environment political, provider associations, agency goals. Experienced in coordinating with other state audit entities. Have established processes for a) Receiving and Formatting Medicaid Data, b) proven provider relations and c) seamless recovery function. 7
Overview of Review Process Analysis And Targeting Program Analysis Data Mining/Scenario Design State Approval Record Request Provider Contact Record Request/Receipt Tracking/follow up Review/Audit RN/Coder Review Physician Referral QA and Client Review/Approval Results and Communications Draft Audit Findings Letter Reconsideration/Appeal Support Education, Process Improvement Provider Association Meetings Program Recommendations Banner/Website 8
Analysis and Targeting Analysis And Targeting Program Analysis Data Mining/Scenario Design State Approval Wrap around existing Indiana Fraud and Abuse Detective System (FADS) and compliment FSSA/OMPP Surveillance and Utilization Review (SUR) efforts. HMS utilizes data mining techniques to target claims where the demographics, billing attributes, diagnosis codes, procedures codes, and/or factors that appears to be inconsistent with other attributes of the claim. OMPP has no immediate plans to utilize extrapolation for RAC audits. 9
Types of Reviews Automated / Complex Automated Review is applied in scenarios where improper payments can be identified clearly and unambiguously. 1. Claims are identified with potential findings. Complex Review is required when analysis identifies a potential improper payment that cannot be automatically validated. 1. Claims are flagged for further review and HMS determines what documentation is required to determine if an improper payment exists. 2. Documentation is requested from the provider or appropriate party and reviewed to determine if an improper payment exists. 10
HMS RAC Support Staff Experienced staff performing reviews: Certified Coders Registered nurses Pharmacy staff Dental staff Therapists Review panel of certified board physicians HMS has in-depth knowledge of: Indiana Medicaid billing & reimbursement practices Claims adjudication process 11
INDIANA MEDICAID RAC
Indiana s Medicaid RAC Program HMS, as the Recovery Audit Contractor (RAC), audit areas Credit Balance Financial Audits Long Term Care Clinical Complex Reviews Current Clinical Complex Review DRG Validation Audit Provider Types Approved to Date Acute Care Hospitals Long Term Care (LTC) Nursing Facilities Acute Care Hospitals Acute Care Hospitals Medical Record Limits Not applicable- Financial Audit only Not applicable-financial Audit only Yes - OMPP will set by Provider Type as audits are approved * Note: OMPP may authorize exception on a case-by-case basis. Provider Type 01 (acute care): 300 records per audit 600 records per CY Maximum freq of request-every 90 days Type of Audit On-site or desk reviews Desk reviews Desk reviews Desk reviews; few could become on-site Audit Notification HMS letterhead FSSA/OMPP letterhead FSSA/OMPP letterhead FSSA/OMPP letterhead Types of Records Aged Trial Balance/ATB Credit Balance Report Debit adjustment reports Other claim documentation Census reports Detailed Aging Report Detailed Financial History Rpt Medical records Varies by audit Medical records For example: Discharge summary Physician orders Labs, x-rays Medication Records 13 13
Indiana s Medicaid RAC Program Additional comparisons by audit area Credit Balance Audit LTC Audit Complex Reviews Current Complex Review DRG Validation Audit Who to Contact? NY, TX, IN field staff CT TX, Indiana licensed MD TX, Indiana licensed MD (Notification includes Contact Information) Source of Audits and Frequency All acute care hospitals: variable based on audit results All LTC nursing facilities: 2 year cycle Data mining and algorithms: variable based on audit results Data mining and algorithms: variable based on audit results Claim Selection Claim-by-claim Claim-by-claim Varies per audit. May use sampling in the future. Claim-by-claim Entrance Conference Yes on-site or by conference call Yes by conference call No, but provider may contact HMS Provider Services anytime No, but provider may contact HMS Provider Services anytime Exit Conference Yes on-site or by conference call to review worksheets No, but HMS will maintain open communication with provider No, but provider may contact HMS Provider Services anytime No, but provider may contact HMS Provider Services anytime 14 14
Complex Reviews Methodology Perform a comprehensive review of fee-for-service claims where data mining/analysis identifies a potential improper payment that cannot be automatically validated. The audits will cover a three-year review period adjusted by a oneyear look-back period from the date when each audit commences. For the ongoing DRG Validation Audits, the time period is July 1, 2008 to June 30, 2011. As we initiate more audits, that time period will be adjusted based on the audit start date and direction from OMPP. In the first phase of DRG Validation Audits, 42 hospitals were selected and HMS is currently working with the first 20. The remaining first phase hospitals will receive notification letters in the coming month. Audits for additional phases of DRG Validation and approved scenarios to follow first phase. 15
Record Request Record Request Provider Contact Record Request/Receipt Tracking/follow up Contact updates from Credit Balance Audits and HMS Provider Services record of contacts. The State and HMS jointly issue a notification letter to Provider, which includes: Attachment of selected claims for review. Examples of the DRGs and procedure codes that HMS will audit. Letter outlines supporting documentation required for submission. Submit within 30 days from the date the notification received. Instructions for paper, CD/DVD or Electronic Data Interchange (EDI). Provider must not submit adjustments/voids for the claims identified. Provider Services contact for questions or follow up requests. 16
Review / Audit Review/Audit RN/Coder Review Physician Referral QA and Review/Approval HMS Complex Review process is tailored to meet the State s policy and procedure requirements. OMPP set RAC audit medical record limits for Provider Type 01 (Hospital) and communicated that decision in banner BR201231 dated July 31, 2012. Audits will be conducted as desk reviews by experienced certified coders with access to a panel of physicians. HMS Medical Director, Dr. Peter Gurk, is an Indiana licensed physician responsible for clinical review operations. During this period, HMS may be in contact with the provider to ask questions or to request additional information. The provider may contact HMS at any time to discuss their review. 17
HMS Responsibilities Results and Communications Draft Audit Findings Letter Reconsideration/Appeal Support Send Draft Audit Findings Letter with results of review. HMS works one-on-one with the provider to resolve any disputed cases, if provider requested reconsideration. When signed appeal waiver is received, coordinate processing of provider claim adjustment requests with Hewlitt Packard. Send Final Calculation of Overpayment letter to provider indicating remaining interest owed after claim adjustment requests have been processed. Amount of overpayment is net difference between original claim payment and payment indicated on adjusted claim plus applicable interest. Support appeals process when applicable. 18
Provider Responsibilities Results and Communications Draft Audit Findings Letter Reconsideration/Appeal Support Review Draft Audit Findings and respond within 45 calendar days of signed receipt of letter and: If provider is in agreement with findings, complete Audit Reconsideration and Appeal Waiver form along with completed claim adjustment requests as indicated in Draft Audit Findings letter. Completed adjustment request form(s) along with corrected claim form(s) must be directed to the OMPP SUR Department. The SUR Department will facilitate the necessary corrections with Hewlett Packard (HP) to allow claims adjustments beyond one-year look back period for claims covered by the audit, or If provider is not in agreement with findings, submit a Request for Administrative Reconsideration and provide supporting documentation. (Not submitting a Request for Administrative Reconsideration within the required 45-day timeframe means the provider forfeits their appeal rights.) Review Final Calculation of Overpayment letter and: Agree and proceed with repayment, or File a timely appeal (would not apply if appeal rights are waived or forfeited through Draft Audit Findings process). (Not filing timely appeal within the required 60-day timeframe forfeits appeal rights.) 19
Process Improvement Education, Process Improvement Provider Association Meetings Program Recommendations Banner/Website Work one-on-one with provider to identify process improvements and educate staff to reduce future billing errors. IHCP publications for updates on Statewide program. Program Integrity Web site for general information such as FAQs. (Web site address available at end of today s presentation.) CMS reporting for information on outcomes. 20
DIAGNOSIS RELATED GROUP (DRG) AUDITS GLENDALLOYD, MBA, BS, RHIA
DRG Validation The purpose of DRG validation is to ensure that diagnostic and procedural information and the discharge status of the member, as coded and reported by the hospital on its claim, matches both the attending physician's description and the information contained in the member s medical record. Refer to IHCP banner page BR201242 dated October 16, 2012. 22
Current Validation Set 1. Septicemia: Reviews will be conducted to validate all information affecting the assignment of AP-DRGs 416 (Septicemia, age greater than 17), 417 (Septicemia, age less than 18), and 584 (Septicemia with major CC). 23
Current Validation Set 2. Operating Room Procedure Unrelated to Principal Diagnosis: Reviews will be conducted of AP- DRGs 468 (Extensive O.R. procedure unrelated to principal diagnosis), 476 (Prostatic O.R. procedure unrelated to principal diagnosis), and 477 (Non-extensive O.R. procedure unrelated to principal diagnosis) to validate if the principal diagnosis is correct as well as address any other coding or compliance issues identified. 24
Current Validation Set 3. Excisional Debridement: Excisional debridement of wound, infection, or burn is defined as the surgical removal or cutting away of devitalized tissue, necrosis, or slough. * HMS will audit excisional debridement procedure code 86.22 to validate the proper use of this code. * AHA Coding Clinic, Fourth Quarter, 1988, page 5 25
Current Validation Set 4. Tracheostomy: Reviews will be conducted of AP-DRGs 482 (Tracheostomy for face, mouth, and neck diagnoses), 483 (Tracheostomy except for face, mouth and neck diagnoses), 700 (Tracheostomy for HIV infection), and procedure codes 31.1 (temporary tracheostomy) or 31.29 (other permanent tracheostomy). 26
CONTACT RESOURCES
Contact Information indianamedicaid.com 1-800-457-4515 www.in.gov/fssa Only formal responses to questions asked through the www.in.gov/fssa inquiry process will be considered official and valid by the State. No participant shall rely upon, take any action, or make any decision based upon any verbal communication with any State employee including responses in today s presentation. 28
WEBSITE - WWW.IN.GOV/FSSA Contact Us 29
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After the Webinar Providers can refer to the Program Integrity Web site for additional information regarding RAC audits. http://provider.indianamedicaid.com/about-indiana-medicaid/programintegrity/medicaid-rac.aspx 31
Q & A Complex Reviews Webinar February 15, 2013